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Controlling the cost of Medicaid private duty nursing services : final report to the Joint Legislative Program Evaluation Oversight Committee

Private Duty Nursing Report No. 2008- 12- 05
Page 12 of 22
present the latest version of the policy to the Physician Advisory Group for
official consideration in early 2009.
The Division of Medical Assistance is considering the following changes to
its private duty nursing policy in an effort to control costs and to establish
more objective and clear criteria for evaluating recipient need for
continuous, complex, and substantial nursing care:
• Requiring that recipients need more individual and continuous
care than is available from a visiting nurse or is routinely
provided by the nursing staff of a hospital or skilled nursing
facility. This requirement is consistent with the United States Centers
for Medicare and Medicaid Services ( CMS) definition of private
duty nursing, but it is not stated explicitly in the current private duty
nursing policy.
• Requiring that there is no equally effective and more
conservative or less costly treatment available statewide. This
requirement would help ensure private duty nursing is not provided
primarily for the convenience of a recipient, a recipient’s caretaker,
or a provider. These requirements would be consistent with
Medicaid’s mission of structuring benefits in a manner that promotes
access to medically necessary and cost- effective care. It would
allow the Private Duty Nursing Team to deny services when a
recipient’s needs could be met by a less expensive service ( e. g.,
intermittent nursing, home health care, and/ or personal care)
and/ or by a less expensive health care provider, such as a nurse
aide.
• Requiring the use of an acuity tool for approval and renewal of
services. In an effort to make medical necessity determinations
more objective, the team— along with the Association for Home and
Hospice Care of North Carolina and representatives of home care
providers— has developed an Hourly Nursing Review Criteria form.
For skilled nursing needs to be considered substantial, a recipient’s
technology needs must meet a minimum threshold.
• Requiring multiple, interrelated nursing assessments. For skilled
nursing needs to be considered complex, a recipient must need
multiple, interrelated nursing assessments requiring interventions
that can only be performed by a licensed nurse.
• Requiring recipients to need hourly nursing assessments and
interventions every two to three hours. For skilled nursing needs
to be considered continuous, a recipient must need hourly nursing
assessments and interventions every two to three hours during the
time period when private duty nursing services are provided. This
requirement would allow the Private Duty Nursing Team to deny
approval of continuous skilled nursing when recipients’ needs could
be met by intermittent skilled nursing or care by nurse aides.
• Requiring that recipients must have a trained caregiver available
at least eight hours per day. The Private Duty Nursing Team bases
its decisions on the medical needs of recipients rather than the
convenience of caregivers. However, caregiver availability

Private Duty Nursing Report No. 2008- 12- 05
Page 12 of 22
present the latest version of the policy to the Physician Advisory Group for
official consideration in early 2009.
The Division of Medical Assistance is considering the following changes to
its private duty nursing policy in an effort to control costs and to establish
more objective and clear criteria for evaluating recipient need for
continuous, complex, and substantial nursing care:
• Requiring that recipients need more individual and continuous
care than is available from a visiting nurse or is routinely
provided by the nursing staff of a hospital or skilled nursing
facility. This requirement is consistent with the United States Centers
for Medicare and Medicaid Services ( CMS) definition of private
duty nursing, but it is not stated explicitly in the current private duty
nursing policy.
• Requiring that there is no equally effective and more
conservative or less costly treatment available statewide. This
requirement would help ensure private duty nursing is not provided
primarily for the convenience of a recipient, a recipient’s caretaker,
or a provider. These requirements would be consistent with
Medicaid’s mission of structuring benefits in a manner that promotes
access to medically necessary and cost- effective care. It would
allow the Private Duty Nursing Team to deny services when a
recipient’s needs could be met by a less expensive service ( e. g.,
intermittent nursing, home health care, and/ or personal care)
and/ or by a less expensive health care provider, such as a nurse
aide.
• Requiring the use of an acuity tool for approval and renewal of
services. In an effort to make medical necessity determinations
more objective, the team— along with the Association for Home and
Hospice Care of North Carolina and representatives of home care
providers— has developed an Hourly Nursing Review Criteria form.
For skilled nursing needs to be considered substantial, a recipient’s
technology needs must meet a minimum threshold.
• Requiring multiple, interrelated nursing assessments. For skilled
nursing needs to be considered complex, a recipient must need
multiple, interrelated nursing assessments requiring interventions
that can only be performed by a licensed nurse.
• Requiring recipients to need hourly nursing assessments and
interventions every two to three hours. For skilled nursing needs
to be considered continuous, a recipient must need hourly nursing
assessments and interventions every two to three hours during the
time period when private duty nursing services are provided. This
requirement would allow the Private Duty Nursing Team to deny
approval of continuous skilled nursing when recipients’ needs could
be met by intermittent skilled nursing or care by nurse aides.
• Requiring that recipients must have a trained caregiver available
at least eight hours per day. The Private Duty Nursing Team bases
its decisions on the medical needs of recipients rather than the
convenience of caregivers. However, caregiver availability